Lymphedema and Exercise

Several research studies have found that a program of gradually increasing exercise supervised by a certified lymphedema therapist — meaning you start gently and intensify slowly over time — is not likely to increase the risk of lymphedema. This is also the recommendation made in the National Lymphedema Network’s Position Statement on Exercise. Some experts believe that exercise may even play a role in rehabilitating the arm so that it can better withstand the day-to-day stresses that can lead to lymphedema.

“I believe that cardiac rehabilitation is a great analogy for this,” says Kathryn Schmitz, PhD, MPH, associate professor in the Division of Clinical Epidemiology at the University of Pennsylvania. “Let’s say you have damage to the heart muscle because of a heart attack. Well, those damaged cells are never coming back. But the more you strengthen the rest of your heart through exercise, the smaller the chance of another problem down the line.

“People who recover from heart attacks go on to run marathons,” she adds. “There is no reason why a woman with damage to her lymphatic system should have to spend the rest of her life avoiding anything that puts too much stress on her arm. Rather, she can take her cue from cardiac rehab and very slowly increase the amount of stress her arm can handle through weight training or other forms of exercise. That way, if she has a day when she gets a bee sting or ends up washing 200 dishes at the church dinner, her arm can handle it. This doesn’t mean throwing all precautions to the wind, though — she still has to be smart about how she uses her arm.”

Dr. Schmitz and her team conducted the Physical Activity and Lymphedema Trial, or PAL, which played a key role in overturning restrictive activity limits on people at risk for lymphedema. The trial enrolled 154 women at risk for breast cancer-related lymphedema, assigning them to either a program of slowly progressive weight training, starting out with very light weights, or no exercise. Among women who had five or more lymph nodes removed, the weight training made a difference: 7% in the intervention group experienced an incident of lymphedema, versus 22% in the no-exercise group.

Also as part of PAL, the research team completed a study with 141 breast cancer survivors who had stable lymphedema, assigning them to either a slowly progressive weight training program or no intervention. Women in the weight-training group were not found to be at any higher risk of developing arm swelling. They also had a lower incidence of lymphedema flare-ups — 14% in the exercise group, versus 29% in the control group — as assessed by a certified lymphedema therapist.

More research is needed to determine whether weight-training and other forms of exercise help reduce the risk of lymphedema and flare-ups. We do know that exercise makes the muscles into a pump that can push lymph fluid where it needs to go. “The lymphatic vessels lie between the muscle and the skin. With activity, the muscle contracts and relaxes against the skin. So by pump and release, the activity massages the lymph vessels and moves extra lymphatic fluid out of there,” says Linda T. Miller, PT, DPT, CLT, clinical director of the Breast Cancer Physical Therapy Center, Ltd., in Malvern, PA.

Designing an exercise plan

Typically, an exercise plan for anyone at risk for or diagnosed with lymphedema includes some combination of:

flexibility and stretching exercises

strength training

aerobic exercise that uses the upper body, helping with weight loss and encouraging deep breathing, which in turn helps lymph move along

“This is very different than simply going out and joining a gym, or starting to run the same 3 or 4 miles you used to do before,” says lymphedema specialist Nicole Stout. “If you are exercising without guidance, it can be difficult to tell the difference between exercising and straining your limb. I always tell women, ‘Start low, go slow, listen to the limb.’ Exercise is important, but you have to do it wisely with specific guidance from someone who knows your situation.”

The following tips may be helpful as you make an exercise plan that is right for you:

If possible, work with a physical medicine doctor, physical therapist, occupational therapist, nurse, massage therapist, or other provider who specializes in lymphedema management and breast cancer rehabilitation. Seek out someone with training and expertise in this area; see Finding a Lymphedema Therapist for guidance. Working with a trainer or therapist NOT schooled in issues specific to breast cancer patients could lead to injury, which increases lymphedema risk. After working with an expert to learn how to exercise properly, eventually you’ll be able to exercise on your own.

Your plan should be individualized to meet your needs and fitness level. Just as there is no “one size fits all” approach to breast cancer treatment, the same holds true for exercise. Every person’s body is different. Strength training with light weights is good for many women, but some may find it too painful or too hard on the arm. In those cases, other forms of gentler exercise may be recommended. Also, if you’re undergoing chemotherapy or taking other medications with side effects, there may be times when you don’t have the energy to exercise.

Start slowly and cautiously, take frequent breaks, and use your arm as a guide. Your lymphedema therapist can help you make a sensible plan for getting active again. If you were active before surgery — for example, lifting weights, running, or biking — you’ll want to work slowly back up to your previous level of activity. Your therapist may recommend that you lift lighter weights, walk, or bike shorter distances on an exercise bike at first. You should stop if your arm feels heavy, achy, or tired. Your therapist can show you stretches to do at these times, as well as for daily maintenance, to keep the lymph moving. If you were moderately active or not active at all before surgery, you’ll want to start even more slowly, paying close attention to how your arm responds. Low-impact exercises such as walking, swimming, or tai chi can be a good way to start.

Watch your arm, hand, and upper body during and after activity for any change in size, shape, tissue, texture, soreness, heaviness, or firmness. Any changes could be a sign that you need to ease up on a particular activity or take a break. If a change persists for more than a few days, see your doctor or therapist.

Keep in mind that lower body and core (abs, back, and pelvis) exercises can affect your upper body. “The effect of strength training for the upper body is pretty obvious; however, some may forget that the risk is also there for core and lower body exercises,” says Cathy Bryan, M.Ed., an American College of Sports Medicine and American Cancer Society Certified Cancer Exercise Trainer. “For instance, two main variables to think about are loading the weights onto plate-loaded equipment (such as a leg press) and gripping handles too tightly during the leg exercise (such as leg extension). When performing core exercises, we must always pay close attention to where our arms and wrists are and if we’re holding weight during the exercise. Again, a safe and effective full-body workout is usually a very attainable goal. This is just another reason to find a qualified personal trainer to help you design and implement your workout.”

Be aware that not all exercise programs for cancer survivors will meet your needs, and some may be risky. Many health clubs, gyms, and hospitals offer exercise programs targeted at cancer survivors. Check out any program you’re considering in advance or run it by your therapist. Even if it’s billed as “cancer rehabilitation,” it may not meet the needs of people at risk for lymphedema.

If you don’t have access to a doctor or therapist with expertise in lymphedema, whether because of location or cost, ask another physical therapist or health care provider to consult with you. Talk to this person about your lymphedema concerns and your plans to exercise. As a medical professional, he or she may be able to request the strength training plan used in the Physical Activity and Lymphedema Trial, available through the PAL website. Another resource is a DVD called Strength & Courage: Exercises for Breast Cancer Survivors, a program of low-impact exercises developed by a breast cancer survivor and health fitness specialist in Pittsburgh, PA.

Expert Quote

"We used to tell women never to lift 5 pounds, 10 pounds for the rest of their lives. That is absolutely not true. Women should be using the arm and exercising, but in a wise way. There is danger in exercise if they overdo it and strain the limb. I have never told a patient, ‘No, you can’t do that’ — whether she wants to try yoga for the first time, get back on the golf course, go rock climbing, or, in one case, even return to power-lifting. It’s a matter of working the limb gradually, exercising it to get in shape to do those activities."